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E-Cigarette Safety? A Case of Combustion Causing Severe Intraoral
Trauma Joseph R. Jacob, MD1; Richard H. Wiggins, MD2; Loren G. Longenecker, MD2; Richard K. Gurgel, MD1
1University of Utah, Division of Otolaryngology; 2University of Utah, Department of Radiology
INTRODUCTION
Electronic nicotine delivery system (ENDS) also known as
electronic cigarettes (or e-cigarettes), have recently become popularized
despite a lack of research on their safety.(1) E-cigarettes are so-called
because of their physical resemblance to the standard tobacco cigarette
and their electronic vapor generating mechanism. In 2004, Ruyan, a
Beijing-based company patented and launched the first of these
devices.(2) Many other manufactures have since made similar devices.
All of these devices contain a mouthpiece, a micro-electrical circuit, a
vaporizer, and a rechargeable lithium ion battery. A solution containing
nicotine is contained in replaceable cartridges or used to fill a reservoir
in some models. When the user draws air through the e-cigarette the
micro-electrical circuit activates an electrical coil to heat and vaporize a
small amount of the nicotine solution, creating a visible cloud of mist
that the user inhales.(3) A case was reported in the lay press of a 57 year
old man whose e-cigarette exploded in his mouth, knocking out his front
teeth and injuring his tongue and soft palate.(4) The exact cause of the
explosion is still unclear, but may have been caused by explosion from
the lithium battery power source.(5) In this report, we describe an
additional case of an e-cigarette exploding, causing significant oral
trauma, leading to an emergent tracheotomy and prolonged
hospitalization.
Daily wound care and bacitracin twice daily was provided for
partial thickness burns to the nose, nares, mouth and cheeks with no
operative management. Patient tolerated tracheostomy capping and was
decannulated six days after the tracheotomy was placed. The following
day the patient was discharged home at baseline oxygen requirements.
CONCLUSIONS
While rare, serious injury can occur from exploding e-cigarettes,
causing significant oral-facial trauma. As we understand the risks of these
devices, we will be better prepared to handle these difficult cases.
REFERENCES •U.S. Food and Drug Administration (2013, April 25). News and Events: Electronic Cigarettes (e-Cigarettes). Retrieved from
http://www.fda.gov/newsevents/publichealthfocus/ucm172906.htm
•Bullen C, Williman J, et al. Study protocol for a randomized controlled trial of electronic cigarettes versus nicotine patch for smoking cessation. BMC Public Health
2013, 13:210
•Trtchounian A, Talbot P. Electronic nicotine delivery system: is there a need for regulation? Tob Control 2011, 20:47-52
•CBS News (2012, February 16). Electronic cigarette explodes in man’s mouth, causes serious injuries. Retrieved from http://www.cbsnews.com/8301-504763_162-
57379260-10391704/electronic-cigarette-explodes-in-mans-mouth-causes-serious-injuries/
•CSP Daily News (2012, February 20). UPDATE: Was Exploding E-Cigarette a “Mod”? Retrieved from http://www.cspnet.com/news/tobacco/articles/update-was-
exploding-e-cigarette-mod
•Regan AK, Promoff G, et al. Electronic nicotine delivery system: adult use and awareness of the “e-cigarette” in the USA. Tob Control 2011, 050044 Published Online
First: 27 October 2011
CASE REPORT
A 50 year old male with history of hypertension and COPD on
home oxygen, was brought to the emergency room after his electronic
cigarette exploded in his face. At the time of the explosion he and his
wife were swapping out flavored nicotine liquids. He was not using his
oxygen at the time. He was using a Prodigy V3 e-cigarette from Pure
Smoker which has 2 lithium batteries stacked on top of each other. The
device was reportedly being used as directed without modification.
After the explosion, the patient was coughing up carbonaceous
sputum as well as blood. A trauma I was called and initial assessment by
trauma team was pertinent for second degree burns to face, fractured
maxillary number 7 and 8 teeth, oral mucosa ulcerations and burns,
edematous palate and erythematous conjunctiva. The patient was then
sent to CT scanner for facial bones CT. CT showed a large soft palate
hematoma containing tooth shrapnel, soft tissue emphysema, and
narrowing of the oropharyngeal airway. (Fig 1)
Upon ENT evaluation, the patient was in respiratory distress with
active bleeding from the mouth precluding evaluation of the palate.
Patient was emergently taken to the OR for fiberoptic intubation and
exam under anesthesia. There was active arterial hemorrhaging from a
soft palate laceration approximately 3cm in size. (Figure 2 and 3)
Laryngoscopy then revealed normal larynx, epiglottis, AE folds, vocal
cords and subglottis. Fractured tooth 7 was extracted. Due to
oropharyngeal edema, a tracheostomy was performed and the patient
was then transferred to the SICU.
DISCUSSION
A government survey concluded that in 2010 2.7% of American
adults had tried vapor smoking.(6) There are approximately 2.5 million
people currently using electronic cigarettes and the number is estimated
to continue growing despite a lack of research on their safety.(4) The
FDA has reported that the safety of e-cigarettes has not been fully
studied.(1) There is a paucity of case reports of other similar injuries in
the medical literature. Although the investigation is still not concluded
in the first event, it does not appear that the incident involved an off-the-
shelf e-cigarette device but rather a custom made modified e-cigarette
that used stacked batteries. These devices are put together by the
consumer and usually are modified to produce a heavy nicotine burst
typically achieved by using lithium batteries lager that those found in
off-the-shelf products. Stacking batteries is a common practice and is
felt to be a risk for battery malfunction. Cheap, unprotected lithium ion
batteries also have the possibility of overcharging and have been known
to explode. An electrical fire inside the device may produce a buildup of
hydrogen gas resulting in an explosion.(5) The manufacturer, V2 Cigs,
have reported that every action against possible electronic issues has
been taken for non-modified off-the shelf devices. There have been
safeguards integrated into the batteries such as automatic shutoff and
smart chargers that prevent overcharging.
In our current case the device was reported to be an off-the-shelf
device without modification but the batteries being used were
aftermarket batteries. No formal investigation has been performed to
delineate an exact cause of the explosion.
Figure 1: Sagittal CT showing large soft palate hematoma containing tooth
shrapnel, soft tissue emphysema, and narrowing of the oropharyngeal airway
Figure 2: Soft palate laceration
Figure 3: Magnified view of soft palate laceration
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